Title Anxiety Dis Ocd and other.pdf ✅

TRANSCRIBERS 2 PSYCHIATRY III Ethel Maureen Pagaddu, MD September 2019 EXIMIUS 2021 Anxiety Disorder II: OBSESSIVE COMPULSIVE DISORDER and other Related Disorders Marky object's love, they retreat from the oedipal position and regress to an intensely ambivalent emotional stage associated with the anal phase o psychogenesis of OCD, therefore, may lie in disturbances in normal growth and development related to the anal- sadistic phase of development • Ambivalence o an important feature of normal children during the anal-sadistic developmental phase; children feel both love and murderous hate toward the same object, sometimes simultaneously o this conflict of opposing emotions is evident in a patient's doing and undoing patterns of behavior and in paralyzing doubt in the face of choices • Magical Thinking o regression uncovers early modes of thought rather than impulses; that is, ego functions as well as id functions are affected by regression Diagnosis and Clinical Features § characterized by good or fair insight, poor insight, or absent insight a) with good or fair insight recognize that their OCD beliefs are definitely or probably not true or may or may not be true b) with poor insight believe their OCD beliefs are probably true, and patients with absent insight are convinced that their beliefs are true § often take their complaints to physicians rather than psychiatrists § most patients with OCD have both obsessions and compulsions- up to 75 % § symptoms of an individual patient can overlap and change with time, but OCD has four major symptom patterns. A. Contamination - most common pattern is an obsession of contamination, followed by washing or accompanied by compulsive avoidance of the presumably contaminated object - Patients with contamination obsessions usually believe that the contamination is spread from object to object or person to person by the slightest contact B. Pathological Doubt - second most common pattern is an obsession of doubt, followed by a compulsion of checking - the obsession often implies some danger of violence (e.g., forgetting to turn off the stove or not locking a door) C. Intrusive Thoughts - the third most common pattern, there are intrusive obsessional thoughts without a compulsion - such obsessions are usually repetitious thoughts of a sexual or aggressive act that is reprehensible to the patient D. Symmetry - fourth most common pattern is the need for symmetry or precision, which can lead to a compulsion of slowness E. Other Symptom Patterns - religious obsessions and compulsive hoarding are common in patients with OCD - compulsive hair pulling and nail biting are behavioral patterns related to OCD - masturbation may also be compulsive § DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder Mental Status Examination § may show symptoms of depressive disorders -50% § especially men, have a higher than average celibacy rate. § married patients have a greater than usual amount of marital discord Differential Diagnosis § Medical Conditions a) associated with basal ganglia diseases, such as Sydenham's chorea and Huntington's disease § Tourette's Disorder a) the two conditions frequently co-occur § Other Psychiatric Conditions a) obsessive-compulsive personality disorder b) psychotic symptoms often lead to obsessive thoughts and compulsive behaviors that can be difficult to distinguish from OCD with poor insight, in which obsessions border on psychosis. c) depression Course and Prognosis § more than half of patients with OCD have a sudden onset of symptoms § onset of symptoms for about 50-70% of patients occurs after a stressful event, such as a pregnancy, a sexual problem, or the death of a relative. § course is usually long but variable; some patients experience a fluctuating course, and others experience a constant one § 20-30% percent of patients have significant improvement in their symptoms, and 40-50% percent have moderate improvement
TRANSCRIBERS 3 PSYCHIATRY III Ethel Maureen Pagaddu, MD September 2019 EXIMIUS 2021 Anxiety Disorder II: OBSESSIVE COMPULSIVE DISORDER and other Related Disorders Marky § the remaining 20-40% percent of patients either remain ill or their symptoms worsen § poor prognosis is indicated by: yielding to (rather than resisting) compulsions, childhood onset, bizarre compulsions, the need for hospitalization, a coexisting major depressive disorder, delusional beliefs, the presence of overvalued ideas (i.e., some acceptance of obsessions and compulsions), and the presence of a personality disorder (especially schizotypal personality disorder). § good prognosis is indicated by: good social and occupational adjustment, the presence of a precipitating event, and an episodic nature of the symptoms Treatment § pharmacological and behavioral treatments have become common § pharmacotherapy, behavior therapy, or a combination of both is effective in significantly reducing the symptoms of patients with OCD § standard approach is to start treatment with an SSRI or clomipramine and then move to other pharmacological strategies if the serotonin-specific drugs are not effective Body Dysmorphic Disorder ü characterized by a preoccupation with an imagined defect in appearance that causes clinically significant distress or impairment in important areas of functioning ü if a slight physical anomaly is actually present, the person's concern with the anomaly is excessive and bothersome ü recognized and named dysmorphophobia more than 100 years ago by Emil Kraepelin, who considered it a compulsive neurosis ü Pierre Janet called it obsession de la honte du corps ( obsession with shame of the body) Epidemiology § a poorly studied condition, partly because patients are more likely to go to dermatologists, internists, or plastic surgeons than to psychiatrists for this condition § prevalence in the United States of 2.4% § most common age of onset is between 15 and 30 years § W>M § Unmarried § coexists with other mental disorders § more than 90% had experienced MDD; about 70 % anxiety disorder; and about 30% had a psychotic disorder Etiology § Unknown § stereotyped concepts of beauty emphasized in certain families and within the culture at large may significantly affect patients with body dysmorphic disorder. § seen as reflecting the displacement of a sexual or emotional conflict onto a nonrelated body part § defense mechanisms: repression, dissociation, distortion, symbolization, and projection Diagnosis § preoccupation with a perceived defect in appearance or overemphasis of a slight defect § at some point during the course of the disorder, the patient performs compulsive behaviors (i.e., mirror checking, excessive grooming) or mental acts (e.g., comparing their appearance to that of others) § causes patients significant emotional distress or markedly impairs their ability to function in important areas Clinical Features § most common concerns involve facial flaws, particularly those involving specific parts (e.g., the nose) § other body parts of concern are hair, breasts, and genitalia. § a proposed variant of dysmorphic disorder among men is the desire to "bulk up" and develop large muscle mass, which can interfere with ordinary living, holding a job, or staying healthy § As many as one-third of patients may be housebound because of worry about being ridiculed for the alleged deformities; and approximately one-fifth of patients attempt suicide. § comorbid diagnoses of depressive disorders and anxiety disorders are common, and patients may also have traits of OCD, schizoid, and narcissistic personality disorders Differential Diagnosis § Anorexia nervosa § Gender identity disorder § Mood-congruent cognitions involving appearance that occur exclusively during a major depressive episode § Avoidant personality disorder or social phobia § Taijin kyofusho, a diagnosis in Japan, is similar to social phobia but has some features that are more consistent with body dysmorphic disorder § Delusional disorder, somatic type Course and Diagnosis § usually begins during adolescence § onset can be gradual or abrupt § usually has a long and undulating course with few symptom-free intervals § the part of the body on which concern is focused may remain the same or may change over time Treatment § surgical, dermatological, dental, and other medical procedures to address the alleged defects is almost invariably unsuccessful § TCAs, MAOis, and pimozide (Orap) have reportedly been useful in individual cases, other data indicate that serotonin-specific drugs-for example, clomipramine (Anafranil) and fluoxetine (Prozac )-reduce symptoms in at least 50% of patients § the coexisting disorder should be treated with the appropriate pharmacotherapy and psychotherapy. § augmentation of the selective serotonin reuptake inhibitor (SSRI) with clomipramine (Anafranil), buspirone (BuSpar), lithium (Eskalith), methylphenidate (Ritalin), or antipsychotics may improve the response rate Relation to Plastic Surgery § only 2 percent of the patients in a plastic surgery clinic had the diagnosis, but DSM-5 reports the figure to be 7 to 8 percent § surgical requests are varied: removal of facial sags, jowls, wrinkles, or puffiness; rhinoplasty; breast reduction or enhancement; and penile enlargement § men who request penile enlargements and women who request cosmetic surgery of the labia of the vagina or the lips of the mouth often are suffering from this disorder
TRANSCRIBERS 4 PSYCHIATRY III Ethel Maureen Pagaddu, MD September 2019 EXIMIUS 2021 Anxiety Disorder II: OBSESSIVE COMPULSIVE DISORDER and other Related Disorders Marky Hording Disorder ü Compulsive hoarding is a common and often disabling phenomenon associated with impairment in such functions as eating, sleeping, and grooming ü hoarding may result in health problems and poor sanitation, particularly when hoarding of animals is involved, and may lead to death from fire or falling ü characterized by acquiring and not discarding things that are deemed to be of little or no value, resulting in excessive clutter of living spaces ü commonly driven by an obsessive fear of losing important items that the person believes may be of use at some point in the future, by distorted beliefs about the importance of possessions, and by extreme emotional attachment to possessions Epidemiology § approximately 2-5 % of the population, although some studies have found lifetime prevalence as high as 14 percent § M=W § more common in single persons § associated with social anxiety, withdrawal, and dependent personality traits § begins in early adolescence and persists throughout the lifespan Comorbidity § most significant comorbidity is found between hoarding disorder and OCD, with as many as 30 percent of OCD patients showing hoarding behavior. § association between hoarding and compulsive buying § high rates of personality disorders which include dependent, avoidant, schizotypal, and paranoid types. § Deficits in attention and executive function that occur in hoarding may resemble those seen in attention- deficit/hyperactivity disorder (ADHD) § OCD patients with hoarding symptoms had a ten times higher rate of developing ADHD than those without § among schizophrenic patients and have been noted in dementia and other neurocognitive disorders. § eating disorders, depression, anxiety disorders, substance use disorders (particularly alcohol dependence), kleptomania, and compulsive gambling § associated with generalized anxiety disorder Etiology § little is known § has shown a familial aspect to hoarding disorder, with about 80% of hoarders reporting at least one first-degree relative with hoarding behavior § lower metabolism in the posterior cingulate cortex and the occipital cortex of hoarders, which may also account for various cognitive impairments within hoarders such as attention and decision-making deficits § a link between hoarding behavior and markers on chromosomes 4q, 5q, andl 7q § catecholamine-0-methyltransferase ( COMT) gene on chromosome 22q 11.21 might contribute to the genetic susceptibility to hoarding Diagnosis § characterized by ( 1) the acquiring of and failure to discard a large amount of possessions that are deemed useless or of little value; (2) greatly cluttered living areas precluding normal activities; and (3) significant distress and impairment in functioning due to hoarding § includes diagnostic specifiers that relate to insight, which may be rated poor, fair, or good Clinical Features § Most hoarders do not perceive their behavior to be a problem § most hoarding patients accumulate possessions passively rather than intentionally, thus clutter accumulates gradually over time. § common hoarded items include newspapers, mail, magazines, old clothes, bags, books, lists, and notes § hoarding poses risks to not only the patient, but also to those around them Differential Diagnosis § OCD and obsessive-compulsive personality disorder § in patients after suffering Brain lesions § moderate to severe Dementia § Schizophrenia § Bipolar disorder Course and Prognosis § chronic condition with a treatment-resistant course § treatment seeking does not usually occur until patients are in their 40s or 50s, even if the hoarding began during adolescence § symptoms may fluctuate throughout the course of the disorder, but full remission is rare § very little insight into their behavior and usually seek treatment under pressure from others § begin hoarding in response to a stressful event, while others report a slow and steady progression throughout life § those who report onset due to a stressful event have a later age of onset than those who do not § those with an earlier age of onset run a longer and more chronic course. Etiology § difficult to treat § effective treatments for OCD have shown little benefit for patients with hoarding disorder. § most effective treatment for the disorder is a cognitive behavioral model that includes training in decision making and categorizing; exposure and habituation to discarding; and cognitive restructuring § goal in treatment is to get rid of a significant amount of possessions, thereby making the living space livable, and to provide the patient with the skills to maintain a positive balance between the amount of possessions and livable space § pharmacological treatment studies using SSRis have shown mixed results